Advances in Radiation Oncology (2021) 6, 100618

www.advancesradonc.org

Critical Review

Hypofractionated Postmastectomy Radiation

Therapy
Mutlay Sayan, MD, Zeinab Abou Yehia, MD, Nisha Ohri, MD and
Bruce G. Haffty, MD*
Department of Radiation Oncology, Rutgers Cancer Institute of New Jersey, Rutgers University, New Brunswick, New
Jersey

Received 25 May 2020; revised 21 October 2020; accepted 9 November 2020

Abstract
Purpose: To provide an overview of the major randomized trials that support the use of hypofractionated post-mastectomy radiation
therapy for locally advanced breast cancer patients.
Methods and Materials: PubMed was systematically reviewed for publications reporting use of of hypofractionated radiation therapy in
patients requiring post-mastectomy radiation.
Results: Standard fractionation, which is typically delivered over 5 to 7 weeks, is considered the standard of care in setting of post-
mastectomy radiation therapy (PMRT). Modern data has helped to establish hypofractionated whole breast irradiation, which consists of
a 3- to 4-week regimen, as a new standard of care for early-stage breast cancer. Hypofractionated whole breast irradiation has also laid
the groundwork for the exploration of a hypofractionated approach in the setting of hypofractionated post-mastectomy radiation therapy.
Conclusions: While standard fractionation remains the most commonly utilized regimen for PMRT, recently published trials support the
safety and efficacy of a hypofractionated approach. Ongoing trials are further investigating the use of hypofractionated PMRT.
Ó 2020 The Authors. Published by Elsevier Inc. on behalf of American Society for Radiation Oncology. This is an open access article
under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

Introduction node-positive patients, often receive adjuvant RT to the

Breast cancer is the most common malignancy among
women worldwide.1 Adjuvant radiation therapy (RT) is
an important component in the multidisciplinary
management in patients with breast cancer. Patients with
early stage disease are often treated with breast
conserving surgery (BCS) followed by adjuvant RT, with
or without systemic agents.2,3 In the postmastectomy
setting, patients with locally advanced disease, such as
Sources of support: Supported in part by the Breast Cancer Research
Foundation.
Disclosures: The authors have no conflicts of interest to report.
* Corresponding author: Bruce G. Haffty, MD; E-mail: hafftybg@cinj.
rutgers.edu
https://doi.org/10.1016/j.adro.2020.11.003
2452-1094/Ó 2020 The Authors. Published by Elsevier Inc. on behalf of American Society for Radiation Oncology. This is an open access article under
the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
chest wall and draining lymphatics. The benefits of
postmastectomy radiation treatment (PMRT) have been
demonstrated in multiple randomized trials, as well as the
Early Breast Cancer Trialists’ Collaborative Group
meta-analysis, showing improved survival among patients
with locally advanced disease.4-7
The most commonly used regimens from prior
randomized trials consisted of 1.8 to 2 Gy delivered daily to
a total dose of 45 to 50 Gy, with an optional 10 to 16 Gy
tumor bed boost. Treatment was delivered to the
breast/chest wall with or without regional nodal irradiation.
This regimen is referred to as standard fractionation (SF).
Hypofractionation consists of delivery of more than 2.0 Gy
daily per fraction over 3 to 4 weeks, to a total dose that is
2 M. Sayan et al
radiobiologically equivalent to the SF.8-11 Although the
efficacy and tolerability of the SF treatment schedule is
well-established, challenges of this prolonged course
include inconvenience to the patient, escalation of health
care costs, and excess use of resources.12-17 Using data
modeling, Khan et al18 demonstrated that wide-spread
adoption of shorter whole breast irradiation (WBI) or
PMRT schedules can result in significantly increased
access and improved survival for patients with breast
cancer, which is particularly important in regions where RT
access is limited. More modern trials designed to compare
standard fractionated WBI (SF-WBI) to hypofractionated
WBI (HF-WBI) regimens in the setting of BCS demon-
strated the safety and efficacy of HF-WBI.8-11 Updated
consensus guidelines have now endorsed an HF approach
for the majority of patients receiving WBI after BCS.19
The data are now evolving on the use of hypofractio-
nation in the postmastectomy setting. Pending outcomes
for ongoing phase III trials, conventional fractionation
remains standard of care in this patient population. In this
article, we review the available data as well as ongoing
randomized trials investigating HF-PMRT.
Methods and Materials
A detailed literature search for studies published up to
October 10, 2020, was implemented with the aid of the
PubMed database. Our query identified 373 articles using
the search item “postmastectomy radiation therapy” and
22 articles with search item “hypofractionated post-
mastectomy.” All titles and abstracts were subsequently
screened to identify relevant articles that addressed the
use of HF RT in patients requiring postmastectomy
radiation. The details of the search results that we
incorporated are listed in the references section of our
article. Major outcomes in terms of tumor control rates
and occurrence of toxicities were extracted from each
study to substantiate our article.
Radiobiological basis and history of
hypofractionation
The optimal radiation fractionation schedule must
provide maximum tumor cell kill while maintaining
Table 1 Retrospective studies on postmastectomy radiation therapy
Author (reference) Number of patients Treatment (Gy/fractions)
32
Ko et al 133 40/16
Bochenek-Cibor et al33 211 45/20
Tovanabutra et al34 334 40-48/15-19
Eldeeb et al35 66 40-45/15-17
Kouloulias et al36 87 43-48/16-21
Abbreviation: NR Z not reported.
Advances in Radiation Oncology: JanuaryeFebruary 2021
minimum normal tissue toxicity.20 Keeping this balance is
complex and depends on multiple factors including dose
per fraction, total dose, and duration of treatment. The
linear quadratic radiobiologic model has been developed
to describe normal tissue and tumor sensitivity to change
in fraction size.21,22 Historically, most tumor types,
including breast cancer, were assumed to be less sensitive
to fractionation changes with high a/b ratios of 8 to 10
Gy, whereas most normal tissues were known to be more
sensitive to change in fraction size with low a/b ratios of
1 to 4 Gy.20,23 It was later discovered, however, that
breast cancer cell lines have a much lower a/b ratio that is
similar to the surrounding normal tissues.22,24,25 These
findings have suggested that a lower total dose in fewer
fractions may be more effective than the standard
fractionation schemes.8,26,27
In addition to this radiobiological evidence, multiple
clinical studies in the 1990s reported excellent local
control and minimal toxicities with hypofractionation.28-30
This has led to the initiation of multiple randomized trials
to compare the efficacy and safety of hypofractionation
with SF in patients with early stage breast cancer. The
results of these European and Canadian trials with
long-term follow-up have demonstrated that HF-WBI is
an appropriate replacement for SF-WBI in most
patients.8,11,31 The radiobiological principles discussed
previously, combined with favorable clinical outcomes
from large randomized trials with long-term follow-up,
have established HF-WBI as the new standard of care.
Efficacy of HF-PMRT
Multiple retrospective studies support promising
outcomes with HF-PMRT (Table 1).32-36 Although some
were largely breast conservation trials, 4 major
prospective clinical trials investigating the efficacy and
toxicity of various hypofractionation regimens included
postmastectomy patients with breast cancer. Key features
of these trials are summarized in Table 2.
One of the first major randomized trials was initiated in
the United Kingdom in 1999.9 The UK Standardization of
Breast Radiotherapy Trial A (START A) included 2236
patients with T1-3a, N0-1, M0 invasive breast cancer who
underwent BCS or mastectomy with surgical margins
1 mm. Patients were randomized to 50 Gy in 25
Follow-up Local control Overall survival
5y 5 y 97.6% 5 y 74.7%
30 mo 3 y 96.4% 3 y 74.6%
66 mo 5 y 96.1% 5 y 64.7%
23 mo 7 y 95.5% 7 y 92.4%
36 mo 3 y 100% NR
Advances in Radiation Oncology: JanuaryeFebruary 2021 Hypofractionated PMRT 3

Table 2 Key features of the hypofractionation trials

Variable START A START B Beijing, China United States
Patients enrolled 2236 2215 820 69
Study years 1998e2002 1999e2001 2008e2016 2010e2014
Median follow-up (y) 9.3 9.9 4.9 4.5
Stage T1-3a, N0-1, M0 T1-3a, N0-1, M0 T3-4, N2-3, M0 T2-4, N1-3, M0
Surgery
Lumpectomy, n (%) 1900 (85) 2038 (92) 0 0
Mastectomy, n (%) 336 (15) 117 (8) 820 (100) 69 (100)
Reconstruction, n (%) d d 0 41 (59)
Treatment arms (Gy/fractions) 50/25 (5 wk) 50/25 (5 wk) 50/25 (5 wk) 36.6/11 (2.2 wk)
41.6/13 (5 wk) 40/15 (3 wk) 43.5/15 (3 wk)
39/13 (5 wk)
Boost
n (%) 1159 (61) 875 (43) 0 67 (97)
Dose (Gy/fractions) 10/5 10/5 13.3/4
Regional nodal irradiation, n (%) 318 (14) 161 (7) 820 (100) 69 (100)
Chemotherapy, n (%) 793 (35) 491 (22) 820 (100) 64 (93)
Abbreviation: START Z Standardisation of Breast Radiotherapy Trials.

fractions (control arm), 41.6 Gy in 13 fractions
(experimental arm), or 39 Gy in 13 fractions
(experimental arm). All treatments were delivered over 5
weeks. An elective nonrandomized boost (10 Gy in 5
fractions) was given at the discretion of the treating
physician in 61% of patients. A total of 15% of patients
underwent mastectomy, 14% received regional nodal
irradiation (RNI), and 35% received adjuvant
chemotherapy before radiation. At 10 years, rates of local
relapse (LR) were 6.7% in the 50 Gy arm, 5.6% in the
41.6 Gy arm, and 8.1% in the 39 Gy arm (P value, not
significant).31 Similarly, disease-free survival (DFS) and
overall survival (OS) were similar between treatment
arms.
The START B trial was initiated in the UK
concurrently with the START A trial.10 Eligibility criteria
in this trial were similar to START A. Between 1999 and
2001, 2215 patients were randomized to 50 Gy in 25
fractions (control arm) or 40 Gy in 15 fractions
(experimental arms). However, in contrast to the START
A trial, the experimental arm completed treatment in only
3 weeks. An elective nonrandomized boost (10 Gy in 5
fractions) was given at the discretion of the treating
physician in 43% of patients. A mastectomy was
performed in 8% of patients, RNI was delivered in 7% of
patients, and chemotherapy was delivered in 22% of
patients. At 10 years, rates of LR were 5.2% in the 50 Gy
arm and 3.8% in the 40 Gy arm (P value, not
significant).31 Surprisingly, distant relapse (16.0% vs
12.3%, P Z .014) and overall mortality (19.2% vs 15.9%,
P Z .042) were significantly higher in the control arm.
Although it is unclear what drove this outcome, it was
thought that the difference in LR was likely too small to
be a contributing factor.
One of the major hindrances in assessing the benefits
of adoption of hypofractionation with RNI is the duration
of follow-up. Although results from several limited trials
are encouraging, a longer follow-up duration can prove
invaluable in arriving at a conclusion regarding the
possible utility of hypofractionation with RNI in both
locally advanced and postmastectomy settings.
Extrapolating from the START trials can provide some
reassurance to treating patients with HF PMRT; however,
the questioning of efficacy of this regimen in this more
advanced patient population is reasonable. Those patients
have more advanced disease and are often treated after
surgery and systemic therapy, and one can argue that the
residual tumor burden in this group of patients is higher
than that in those less advanced patients. Our radiation
biology knowledge ensures equivalent tumoricidal
activity with hypofractionation; nevertheless, further
clinical investigation remains necessary.
It is worth noting the British Colombia Canadian trial,
published in New England Journal of Medicine in 1997,
randomized node positive postmastectomy women to
chemotherapy alone versus chemotherapy plus PMRT.
The PMRT arm used an HF regimen of 15 fractions in 2.5
Gy per fraction to the chest wall and regional lymph
nodes using cobalt machines. At 15 years of follow-up,
the HF-PMRT regimen resulted in significant reduction in
recurrence rate of 33% (risk ratio, 0.67; 95% confidence
interval [CI], 0.50-0.90) and a significant reduction in
breast-cancer specific mortality of 29% (risk ratio, 0.71;
95% confidence interval, 0.51-0.99). Although cosmetic
outcomes and long-term side effects were not formally
evaluated in this study, there were no reports of grade 3
toxicity and they noted no cases of brachial plexopathy at
15 years of follow-up.
4 M. Sayan et al
More recently, in Beijing, China, 820 patients with
locally advanced breast cancer (T3-4 or N2) who
underwent mastectomy with axillary lymph node
dissection were randomized to SF-PMRT (50 Gy in 25
fractions) or HF-PMRT (43.5 Gy in 16 fractions).37 All
patients received adjuvant (75%) or neoadjuvant (25%)
chemotherapy. Radiation treatment was delivered to the
unreconstructed chest wall, supraclavicular region, and
level III axillary region. The level I to II axillary regions
and the internal mammary chain were not targeted. The
chest wall was treated with 6 to 9 MeV electrons with a
5-mm tissue equivalent bolus. The supraclavicular
region was most commonly treated with a 2-dimensional
technique prescribed to a depth of 3 cm beneath the skin.
At a median follow-up of 58.5 months, the 5-year
cumulative incidence of locoregional recurrence was
8.1% in the SF-PMRT arm and 8.3% in the HF-PMRT
arm, indicating that HF-PMRT was noninferior to
SF-PMRT. Similarly, DFS (74% vs 70%) and OS (84%
vs 86%) did not significantly differ between the arms.
Given the eligibility criteria that included patients with
advanced disease as detailed previously, those
equivalent findings at 5 years are reassuring. However,
we acknowledge the limitations to applying these data to
the patients in the United States (US) given the
differences in the technology used, such as the use of
electron fields, 2-dimensional RT, and omission of
internal mammary nodes coverage. Also, in this study,
only 55% of patients with HER2-positive cancers were
treated with trastuzumab. This may have meaningful
implications when extrapolating long-term toxicity,
particularly cardiac toxicity outcomes.
In the United States, a prospective phase II HF-
PMRT trial enrolled 96 patients to receive a dose of
36.63 Gy in 11 fractions, delivered 5 days a week, to
the chest wall or reconstructed breast and the regional
lymphatics.38 Eligible patients had stage IIA to IIIC
invasive breast cancer and were allowed to undergo
breast reconstruction, receive neoadjuvant/adjuvant
chemotherapy, and antihormone therapy. High-risk
features such as lympho-vascular invasion, close
margins, young age, and negative hormone receptors
were allowed in this study. Coverage of the internal
mammary nodes was not required but occurred in 54%
of patients. An optional mastectomy scar boost (3.33
Gy  4 fractions) was given at the discretion of the
treating physician in 97% of patients. Forty-three
patients (45%) underwent breast reconstruction (93%
underwent reconstruction before HF-PMRT and 7%
after HF-PMRT). The primary endpoint was freedom
from grade 3 or higher late nonreconstruction-related
radiation toxicities. At a median follow-up of 54
months, there were no acute or late grade 3 and 4
nonreconstruction toxicities. At 5 years, the rate of
locoregional recurrence was 4.6%, distant DFS 77%,
and OS 90%.39
Advances in Radiation Oncology: JanuaryeFebruary 2021
Acute toxicity
The START A and B trials did not report on acute
toxicity; however, in the HF-PMRT trial from China,
overall acute grade 3 skin toxicity was significantly
reduced with HF-PMRT compared with SF-PMRT (3%
vs 8%, P < .0001).37 Otherwise, there were no significant
differences between groups in the incidence of other acute
toxicities. In the US phase II HF-PMRT trial, there were
no acute grade 3 toxicities, and only 24% of the patients
reported acute grade 2 skin toxicity.38 Additionally, a
number of retrospective studies have reported that patients
who received HF-PMRT experienced significantly lower
or similar rates of acute skin toxicity compared with those
who received SF-PMRT.32-34,36,40,41
Late toxicity
In START trials, rates of late toxicities (including
breast shrinkage, arm edema, shoulder stiffness,
telangiectasias) either favored HF-PMRT or were similar
between HF-PMRT and SF-PMRT. Long-term analysis
of these trials also showed very low rates of ischemic
heart disease (0.8% in START A and 1.1% in START B),
symptomatic rib fractures (0.1% in START A and 0.3% in
START B), and radiation pneumonitis (0.1% in START
A and 0.5% in START B), with no differences between
HF-PMRT and SF-PMRT.31,42 In the HF-PMRT trial
from China, there were no significant differences in late
toxicities between the HF-PMRT and SF-PMRT arms,
including radiation pneumonitis (grade  2, 15% vs 10%;
P Z .081), lymphedema (grade  3, 20% vs 21%;
P Z .961), ischemic heart disease (grade  3, 1.7% vs
1%; P Z .569), and shoulder dysfunction (grade  3, 2%
vs 3.4%; P Z .734).37 In the US HF-PMRT trial, no
grade 3 late toxicities were reported. The most common
late toxicity was grade 1 skin toxicity, occurring in 30%
of the patients, usually as hyperpigmentation. Long-term
analysis of this trial additionally showed a low rate of
grade 2 toxicities, including chest wall pain (8%), fatigue
(3%), and lymphedema (2%).39
Although radiation-induced brachial plexopathy is a
concern, this has become an increasingly rare entity in
patients receiving HF-PMRT in the modern era
(Table 3).8,31,37,39,43-53 According to Galecki et al,51 the
risk of radiation-induced plexopathy was less than 1%
when the total dose administered was in the range of 34 to
40 Gy. Surgical manipulation and chemotherapy are
additional factors that can lead to brachial plexopathy.51 It
has also been reported that when the biological effective
dose exceeds 55 Gy, the risk of radiation-induced brachial
plexopathy increases rapidly.51 The 2 Gy equivalent dose
(EQD2) of historic HF-PMRT regimens are estimated to
be significantly higher than the tolerance of brachial
plexus.38 A Swedish study with estimated EQD2 of 76 Gy
Advances in Radiation Oncology: JanuaryeFebruary 2021 Hypofractionated PMRT 5

Table 3 The brachial plexopathy rate with postmastectomy radiation therapy or regional nodal irradiation
First author Period Patient no. RNI dose (Gy) Fractions EQD2* Plexopathy rate (%) Median follow-up (yr)
43
Stoll 1958-1962 117, PMRT 63 12 114.2 73 2.5
Johansson44 1963-1965 71, PMRT 57 17 76.3 63 34
Bajrovic45 1980-1993 140, RNI 52 20 59.8 14 8
Bates46 1968-1974 411, PMRT 35 6 68.5 NR 10
50 12 77.1 NR
Baillet47 1984-1989 230, RNI not reported 23 4 44.6 NR 5
Rodger48 1979-1982 484, PMRT and RNI 45 10 66.4 1 10
1982-1984 289, PMRT and RNI 45 20 43.8 1
Ragaz49 1979-1986 318 (164 PMRT) 35 16 37 0 20
Powell50 1982-1984 338 45 15 56 6 5.5
111 54 30 51 1
Owen8 1986-1998 290 (2/3rd HF) 42.9 13 47-49 0 8
39
Haviland31 1998-2002 479 (278 HF) 40 13-15 47-49 <1 9.3
42.9
39
Wang37 2008-2016 820, PMRT and RNI 50 25 50 0 4.9
43.5 15 53.3
Poppe39 2010-2014 69, PMRT and RNI 36.6 11 48.7 0 4.5
Abbreviations: EQD2 Z 2-Gy equivalent dose; HF Z hypofractionated; NR Z not reported; PMRT Z postmastectomy radiation therapy;
RNI Z regional nodal irradiation.
* Alpha/beta ratio of 2 Gy assumed for normal tissues in EQD2 calculations.

and an Australian study with estimated EQD2 of 114 Gy
reported very high rates of brachial plexopathy, at 63%
and 73%, respectively.43,44 With better understanding of
the radiobiology of breast cancer and development of
modern planning and treatment techniques, the rate of
radiation-induced brachial plexopathy has decreased over
time.49,50 There was only 1 reported case of brachial
plexopathy among all patients treated in the START trials.
There were no cases of brachial plexopathy in the recently
published trials from China or the United States.
A study by Haviland et al54 analyzed the results of
adjuvant lymph node RT in START-A and START-B
trials, focusing on the late normal tissue effects of the
arm and shoulder. They observed that there was no
statistically significant difference in physician-assessed
shoulder stiffness and arm edema between the HF
schedules and control groups in both START-A and
START-B groups. They thus concluded that HF RT is
relatively safe when appropriately dosed.
The Selective Use of Postoperative Radiotherapy after
Mastectomy trial, a randomized, controlled trial included
1688 patients with intermediate-risk breast cancer and
was aimed at understanding the quality of life (QOL) after
postmastectomy RT.55 Velikova et al55 found that no
differences were noted between the treatment and control
groups in fatigue, shoulder and arm symptoms, body
image, physical function, and overall QOL. However,
they noted that patients who received postmastectomy RT
had significantly higher localized chest wall symptoms for
up to 2 years postradiation compared with the no-RT
group.
Breast reconstruction and cosmesis
Although15% of the patients in START A and 8% in
START B trials underwent mastectomy, there was no
description of breast reconstruction in these patients.
Assessment of the moderate or marked breast change in
all patients of the START trials favored HF-WBI over
SF-WBI at 10 years.31 Breast shrinkage and induration
were the most common late normal tissue effects in the
START trials. Moderate or marked breast shrinkage,
telangiectasia, and breast edema were significantly lower
with HF-WBI than with SF-WBI.31 Furthermore, patients
randomized to HF-WBI in the START B trial were less
likely to have a change in skin appearance based on
photographic and patient self-assessments.10
Breast reconstruction after mastectomy has become
more common and has been shown to provide a
significant improvement in most QOL measures.56-63
Studies have demonstrated that SF-PMRT after breast
reconstruction increases reconstructive complication
rates.64-69 A meta-analysis of 6257 patients treated by
SF-PMRT reported a reconstructive complication rate of
41% in implant-based reconstruction, including a
reconstruction failure rate of 17%, an infection rate of
13.5%, and a capsular contracture rate of 38%.70 The
HF-PMRT trial from China was limited to patients who
did not undergo breast reconstruction.37 However, in the
US phase II HF-PMRT trial, 43 patients (45%) underwent
breast reconstruction.39 Reconstructions were commonly
performed before HF-PMRT (93%) and consisted of
temporary expanders (88%), permanent implants (7%),
6 M. Sayan et al
and prior augmentation implants (5%). A total of 35% of
the patients had grade 3 or 4 reconstruction complications
attributable to RT in this trial.
Future directions
Based on the available data, HF-PMRT appears
noninferior to and has similar toxicities to SF-PMRT in
patients with high-risk breast cancer on short-term
follow-up. A meta-analysis and systematic review by
Liu et al71 included 25 clinical trials with a total of 3871
postmastectomy patients with breast cancer. They
concluded that HF RT was not significantly different in
either efficacy or toxicity compared with conventional RT
in this patient population and emphasized the need for
larger randomized control trials. However, data on the
safety of HF-PMRT in patients with breast reconstruction
remain limited. Ideally, it is anticipated that HF-PMRT
would minimize the frequency of complications without
compromising cosmesis. As the use of breast
reconstruction increases, it becomes particularly
important to understand the relationship between RT
regimen and reconstructive outcomes. The ongoing
Alliance A221505 trial (RT CHARM: phase III
Randomized Trial of Hypofractionated Post Mastectomy
Radiation with Breast Reconstruction) is randomizing
patients undergoing mastectomy with immediate or
delayed reconstruction to HF-PMRT (42.56 Gy in 16
fractions) or SF-PMRT (50 Gy in 25 fractions). RNI with
the same dose regimen is required, but mastectomy scar
boost is not allowed. The target enrollment is 880 patients
with a primary endpoint of reconstruction complication
rate. Secondary endpoints include recurrence free survival
and toxicities, including brachial plexopathy and
lymphedema. Another ongoing trial (FABREC: Study of
Radiation Fractionation on Patient Outcomes After Breast
REConstruction for Invasive Breast Carcinoma) is
randomizing patients undergoing mastectomy with
immediate reconstruction to HF-PMRT (42.56 Gy in 16
fractions) or SF-PMRT (50 Gy in 25 fractions). The
primary endpoint of this trial is the patient-reported
outcomes at 6 months.
Conclusions
For decades, adjuvant RT has been an established
standard of care after mastectomy for locally advanced
breast cancer. Although standard fractionation over a
course of 5 to 7 weeks has been historically used to
achieve excellent tumor control with low toxicity, this
regimen can be inconvenient for patients and can increase
health care costs. Although HF-WBI has been established
as a standard of care for the majority of patients with
early-stage breast cancer, the expanded use of an HF
approach in the settings of postmastectomy and regional
Advances in Radiation Oncology: JanuaryeFebruary 2021
nodal irradiation is an area of active investigation. Early
results support the safety and efficacy of HF-PMRT.
Based on long-term data and results of ongoing trials, HF-
PMRT may evolve into a new standard of care.
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